DOCSLIB.ORG

Use of Left Ventricular Assist Devices As Destination Therapy in End-Stage Congestive Heart Failure: a Systematic Review

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Use of Left Ventricular Assist Devices As Destination Therapy in End-Stage Congestive Heart Failure: a Systematic Review Department of Veterans Affairs Health Services Research & Development Service Evidence-based Synthesis Program Use of Left Ventricular Assist Devices as Destination Therapy in End-Stage Congestive Heart Failure: A Systematic Review May 2012 Prepared for: Investigators: Department of Veterans Affairs Principal Investigators: Veterans Health Administration Thomas S. Rector, Ph.D. Quality Enhancement Research Initiative Brent C. Taylor, Ph.D., M.P.H. Health Services Research & Development Service Washington, DC 20420 Research Associates: Nancy Greer, Ph.D. Prepared by: Indulis Rutks, B.S. Evidence-based Synthesis Program (ESP) Center Minneapolis VA Medical Center Minneapolis, MN Timothy J. Wilt, M.D., M.P.H., Director Use of Left Ventricular Assist Devices as Destination Therapy in End-Stage Congestive Heart Failure: A Systematic Review Evidence-based Synthesis Program PREFACE Quality Enhancement Research Initiative’s (QUERI) Evidence-based Synthesis Program (ESP) was established to provide timely and accurate syntheses of targeted healthcare topics of particular importance to Veterans Affairs (VA) managers and policymakers, as they work to improve the health and healthcare of Veterans. The ESP disseminates these reports throughout VA. QUERI provides funding for four ESP Centers and each Center has an active VA affiliation. The ESP Centers generate evidence syntheses on important clinical practice topics, and these reports help: • develop clinical policies informed by evidence, • guide the implementation of effective services to improve patient outcomes and to support VA clinical practice guidelines and performance measures, and • set the direction for future research to address gaps in clinical knowledge. In 2009, the ESP Coordinating Center was created to expand the capacity of QUERI Central Office and the four ESP sites by developing and maintaining program processes. In addition, the Center established a Steering Committee comprised of QUERI field-based investigators, VA Patient Care Services, Office of Quality and Performance, and Veterans Integrated Service Networks (VISN) Clinical Management Officers. The Steering Committee provides program oversight, guides strategic planning, coordinates dissemination activities, and develops collaborations with VA leadership to identify new ESP topics of importance to Veterans and the VA healthcare system. Comments on this evidence report are welcome and can be sent to Nicole Floyd, ESP Coordinating Center Program Manager, at [email protected]. Recommended citation: Rector TS, Taylor BC, Greer N, Rutks I, and Wilt TJ. Use of Left Ventricular Assist Devices as Destination Therapy in End-Stage Congestive Heart Failure: A Systematic Review. VA-ESP Project #09-009; 2012. This report is based on research conducted by the Evidence-based Synthesis Program (ESP) Center located at the Minneapolis VA Medical Center, Minneapolis, MN funded by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative. The findings and conclusions in this document are those of the author(s) who are responsible for its contents; the findings and conclusions do not necessarily represent the views of the Department of Veterans Affairs or the United States government. Therefore, no statement in this article should be construed as an official position of the Department of Veterans Affairs. No investigators have any affiliations or financial involvement (e.g., employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in the report. i Use of Left Ventricular Assist Devices as Destination Therapy in End-Stage Congestive Heart Failure: A Systematic Review Evidence-based Synthesis Program TABLE OF CONTENTS EXECUTIVE SUMMARY Background .................................................................................................................................................... 1 Methods ......................................................................................................................................................... 1 Data Synthesis ............................................................................................................................................... 2 Peer Review ................................................................................................................................................... 2 Results ........................................................................................................................................................... 2 Recommendations for Future Research ......................................................................................................... 4 INTRODUCTION ............................................................................................................................................... 5 Ventricular Assist Devices Approved for Use as Destination Therapy ......................................................... 6 Centers for Medicare and Medicaid Services (CMS) Coverage ................................................................... 6 Registry of Ventricular Assist Devices Used as Destination Therapy ........................................................... 7 Guideline Recommendations ......................................................................................................................... 7 METHODS Topic Development ........................................................................................................................................ 9 Search Strategy .............................................................................................................................................. 9 Study Selection ............................................................................................................................................ 10 Data Abstraction .......................................................................................................................................... 12 Quality Assessment ..................................................................................................................................... 12 Rating the Body of Evidence ....................................................................................................................... 13 Data Synthesis ............................................................................................................................................. 14 Peer Review ................................................................................................................................................. 14 RESULTS Literature Search ......................................................................................................................................... 15 Key Question #1. How does use of an FDA-approved, current generation LVAD as destination therapy (i.e., the HeartMate II left ventricular assist device) effect patient outcomes? .............................. 15 Key Question #2. What patient or site characteristics have been associated with patient benefits or harms when the FDA-approved, current generation LVAD is used as destination therapy? .................. 17 Key Question #3. What is the range of cost-effectiveness estimates of using the FDA-approved, current generation LVAD as destination therapy in end-stage heart failure and what explains variation in these estimates? ........................................................................................................................ 19 SUMMARY AND DISCUSSION Summary Points ........................................................................................................................................... 21 Limitations ................................................................................................................................................... 21 Recommendations for Future Research ....................................................................................................... 21 Conclusions ................................................................................................................................................. 23 REFERENCES ................................................................................................................................................... 24 ii Use of Left Ventricular Assist Devices as Destination Therapy in End-Stage Congestive Heart Failure: A Systematic Review Evidence-based Synthesis Program FIGURES Figure 1. Analytic Framework ................................................................................................................. 10 Figure 2. Literature Flow Diagram .......................................................................................................... 15 APPENDIX A. Technical Expert Panel Mem B ers ............................................................................ 27 APPENDIX B. Search Strategy ............................................................................................................... 28 APPENDIX C. Peer Revie W Comments /Author Responses .......................................................... 29 APPENDIX D. Evidence TA B les Table 1. Key Question #1: Effects on Patient Outcomes ...................................................................... 34 Table 2. Key Question #2: Patient Selection ........................................................................................
Load more

Recommended publications
  • Mechanical Circulatory Support As Bridge Therapy for Heart Transplant: Case Series Report Javier D
    Garzon‑Rodriguez et al. BMC Res Notes (2018) 11:430 https://doi.org/10.1186/s13104-018-3515-2 BMC Research Notes CASE REPORT Open Access Mechanical circulatory support as bridge therapy for heart transplant: case series report Javier D. Garzon‑Rodriguez1, Carlos Obando‑Lopez2, Manuel Giraldo‑Grueso3* , Nestor Sandoval‑Reyes2, Jaime Camacho2 and Juan P. Umaña2 Abstract Background: Mechanical circulatory support (MCS) represents an efective urgent therapy for patients with cardiac arrest or end-stage cardiac failure. However, its use in developing countries as a bridge therapy remains controversial due to costs and limited duration. This study presents fve patients who underwent MSC as bridge therapy for heart transplantation in a developing country. Case presentation: We present fve patients who underwent MCS as bridge therapy for heart transplant between 2010 and 2015 at Fundación Cardioinfantil-Instituto de Cardiología. Four were male, median age was 36 (23–50) years. One patient had an ischemic cardiomyopathy, one a lymphocytic myocarditis, two had electrical storms (recurrent ventricular tachycardia) and one an ischemic cardiomyopathy with an electrical storm. Extracorporeal life sup‑ port (ECLS) was used in three patients, left ventricular assistance in one, and double ventricular assistance in one ­(Levitronix® ­Centrimag®). Median assistance time was 8 (2.5–13) days. Due to the inability of cardiopulmonary bypass weaning, two patients required ECLS after transplant. One patient died in the intensive care unit due to type I graft rejection. Endpoints assessed were 30-day mortality, duration of bridge therapy and complications related to MCS. Patients that died on ECLS, or were successfully weaned of ECLS were not included in this study.
    [Show full text]
  • Periprocedural Management of Oral Anticoagulation
    Nicole Hlavacek, PharmD candidate; Drew McMillan, PharmD Periprocedural management candidate; Jeremy Vandiver, PharmD, BCPS University of Wyoming of oral anticoagulation: School of Pharmacy, Laramie (Ms. Hlavacek, Mr. McMillan, and Dr. Vandiver); When and how to hit “pause” Swedish Family Medicine Residency, Littleton, Colo (Dr. Vandiver) Here’s how best to assess patients’ bleeding and [email protected] thrombotic risks and 5 key questions to ask as you The authors reported no consider withholding oral anticoagulants. potential conflict of interest relevant to this article. CASE 1 u PRACTICE Debra P is a 62-year-old African American woman who calls RECOMMENDATIONS your office to report that she has an upcoming routine colo- ❯ Don’t stop oral antico- noscopy planned in 2 weeks. She has been taking warfarin agulation for procedures with for the past 2 years for ischemic stroke prevention secondary minimal bleeding risk, such as minor dermatologic, dental, to atrial fibrillation (AF), and her gastroenterologist recom- or ophthalmic procedures. C mended that she contact her family physician (FP) to discuss periprocedural anticoagulation plans. Ms. P is currently tak- ❯ Reserve periprocedural ing warfarin 5 mg on Mondays, Wednesdays, and Fridays, bridging with a parenteral an- ticoagulant for those patients and 2.5 mg all other days of the week. Her international nor- on warfarin who are at high- malized ratio (INR) was 2.3 when it was last checked 2 weeks est risk for thromboembolism ago, and it has been stable and within goal range for the past (those with severe thrombo- 6 months. Her medical history includes AF, well-controlled philia, active thrombosis, or hypertension, and type 2 diabetes mellitus, as well as gout and mechanical heart valves).
    [Show full text]
  • Organ Transplant Discrimination Against People with Disabilities Part of the Bioethics and Disability Series
    Organ Transplant Discrimination Against People with Disabilities Part of the Bioethics and Disability Series National Council on Disability September 25, 2019 National Council on Disability (NCD) 1331 F Street NW, Suite 850 Washington, DC 20004 Organ Transplant Discrimination Against People with Disabilities: Part of the Bioethics and Disability Series National Council on Disability, September 25, 2019 This report is also available in alternative formats. Please visit the National Council on Disability (NCD) website (www.ncd.gov) or contact NCD to request an alternative format using the following information: [email protected] Email 202-272-2004 Voice 202-272-2022 Fax The views contained in this report do not necessarily represent those of the Administration, as this and all NCD documents are not subject to the A-19 Executive Branch review process. National Council on Disability An independent federal agency making recommendations to the President and Congress to enhance the quality of life for all Americans with disabilities and their families. Letter of Transmittal September 25, 2019 The President The White House Washington, DC 20500 Dear Mr. President, On behalf of the National Council on Disability (NCD), I am pleased to submit Organ Transplants and Discrimination Against People with Disabilities, part of a five-report series on the intersection of disability and bioethics. This report, and the others in the series, focuses on how the historical and continued devaluation of the lives of people with disabilities by the medical community, legislators, researchers, and even health economists, perpetuates unequal access to medical care, including life- saving care. Organ transplants save lives. But for far too long, people with disabilities have been denied organ transplants as a result of unfounded assumptions about their quality of life and misconceptions about their ability to comply with post-operative care.
    [Show full text]
  • Ventricular Assist Devices (Vads) and Total Artificial Hearts These Services May Or May Not Be Covered by Your Healthpartners Plan
    Ventricular assist devices (VADs) and total artificial hearts These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. Administrative Process Prior authorization is required for insertion of an implantable ventricular assist device (VAD). Prior authorization is required for placement of a total artificial heart (TAH). Prior authorization is not required in the event that either of the devices listed above is used under emergency circumstances for a critically ill member in an in-patient setting. Emergency use is defined as necessary to save the life or protect the immediate well-being of a given patient. However, services with specific coverage criteria may be reviewed concurrently or retrospectively to determine medical necessity. Prior authorization is not required for percutaneous ventricular assist devices (pVADs). Coverage Insertion of an implantable ventricular assist device (VAD) or total artificial heart (TAH) is covered per the member’s plan documents when the criteria outlined below are met and the procedure is performed at a HealthPartners Transplant Center of Excellence. Please see the Related Content section for the Transplant Centers of Excellence documents. Indications that are covered Implantable ventricular assist device Adult 1. An implantable VAD is covered as a bridge to recovery in patients with a potentially reversible condition when the following criteria are met: A. The requested device has received approval from the Food and Drug Administration (FDA) and is being used in accordance with device-specific, FDA-approved indications.
    [Show full text]
  • Decisional Considerations in Left Ventricular Assist Device for Destination Therapy Megan Laila Morrison a Dissertation Submitte
    1 Decisional Considerations in Left Ventricular Assist Device for Destination Therapy Megan Laila Morrison A dissertation Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy University of Washington 2016 Reading Committee: Ardith Doorenbos, Chair Barbara McGrath J. Randall Curtis Program Authorized to Offer Degree: School of Nursing 2 © Copyright 2016 Megan L. Morrison 3 University of Washington Abstract Decisional Considerations in Left Ventricular Assist Device for Destination Therapy Megan L. Morrison Chair of the Supervisory Committee: Professor Ardith Z. Doorenbos School of Nursing End-stage heart failure is a growing problem in the United States as well as world-wide. The definitive treatment in heart failure that is refractory to medical treatment is a heart transplant. But there are a limited numbers of hearts available for transplant and a growing number of patients in need. There has recently been tremendous development in the area of mechanical circulatory support. One of these developments is the left ventricular assist device (LVAD). The LVAD is a pump that assists the failing left ventricle of the heart. The LVAD has proven to increase survival and improve symptoms of end-stage heart failure. Initially the LVAD was used to support patients with heart failure to survive to either recovery or heart transplant, thus termed a bridge therapy. But eventually these devices would be implanted without the intent of heart transplant or recovery, becoming known as destination therapy. A third category of LVAD designation is called bridge to candidacy. In this category 4 patients undergo the implantation of the LVAD and then are later determined whether they are appropriate for heart transplant.
    [Show full text]
  • 280 Total Artificial Hearts and Implantable Ventricular Assist
    Medical Policy Total Artificial Hearts and Implantable Ventricular Assist Devices Table of Contents • Policy: Commercial • Coding Information • Information Pertaining to All Policies • Policy: Medicare • Description • References • Authorization Information • Policy History Policy Number: 280 BCBSA Reference Number: 7.03.11 Related Policies • Heart/Lung Transplant, #269 • Heart Transplant, #197 • Extracorporeal Membrane Oxygenation, #726 Policy Commercial Members: Managed Care (HMO and POS), PPO, and Indemnity Bridge to Transplantation Implantable ventricular assist devices (VADs) with Food and Drug Administration (FDA) approval or clearance may be considered MEDICALLY NECESSARY as a bridge to heart transplantation for patients who are currently listed as heart transplantation candidates and not expected to survive until a donor heart can be obtained, or are undergoing evaluation to determine candidacy for heart transplantation. Implantable (VADs) with FDA approval or clearance, including humanitarian device exemptions, may be considered MEDICALLY NECESSARY as a bridge to heart transplantation in children 16 years old or younger who are currently listed as heart transplantation candidates and not expected to survive until a donor heart can be obtained, or are undergoing evaluation to determine candidacy for heart transplantation. Total artificial hearts (TAHs) with FDA-approved devices may be considered MEDICALLY NECESSARY as a bridge to heart transplantation for patients with biventricular failure who have no other reasonable medical
    [Show full text]
  • Use of Extracorporeal Membrane Oxygenation in Patients with Acute High-Risk Pulmonary Embolism: a Case Series with Literature Review
    Acute and Critical Care 2019 May 34(2):148-154 Acute and Critical Care https://doi.org/10.4266/acc.2019.00500 | pISSN 2586-6052 | eISSN 2586-6060 Use of extracorporeal membrane oxygenation in patients with acute high-risk pulmonary embolism: a case series with literature review You Na Oh1, Dong Kyu Oh1, Younsuck Koh1, Chae-Man Lim1, Jin-Won Huh1, Jae Seung Lee1, Sung-Ho Jung2, Pil-Je Kang2, Sang-Bum Hong1 Departments of 1Pulmonary and Critical Care Medicine and 2Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Background: Although extracorporeal membrane oxygenation (ECMO) has been used for the treatment of acute high-risk pulmonary embolism (PE), there are limited reports which focus Original Article on this approach. Herein, we described our experience with ECMO in patients with acute high-risk PE. Received: April 10, 2019 Revised: May 16, 2019 Methods: We retrospectively reviewed medical records of patients diagnosed with acute high- Accepted: May 18, 2019 risk PE and treated with ECMO between January 2014 and December 2018. Results: Among 16 patients included, median age was 51 years (interquartile range [IQR], 38 Corresponding author to 71 years) and six (37.5%) were male. Cardiac arrest was occurred in 12 (75.0%) including Sang-Bum Hong two cases of out-of-hospital arrest. All patients underwent veno-arterial ECMO and median Department of Pulmonary and Critical Care Medicine, Asan Medical ECMO duration was 1.5 days (IQR, 0.0 to 4.5 days). Systemic thrombolysis and surgical embo- Center, University of Ulsan College lectomy were performed in seven (43.8%) and nine (56.3%) patients, respectively including of Medicine, 88 Olympic-ro 43-gil, three patients (18.8%) received both treatments.
    [Show full text]
  • Anticoagulation Protocol
    ANTICOAGULATION PROTOCOL Federal Bureau of Prisons Clinical Guidance MARCH 2018 This Anticoagulation Protocol is made available to the public for informational purposes only. The Federal Bureau of Prisons (BOP) does not warrant this guidance for any other purpose, and assumes no responsibility for any injury or damage resulting from the reliance thereof. Proper medical practice necessitates that all cases are evaluated on an individual basis and that treatment decisions are patient specific. Consult the BOP Clinical Guidance Web page to determine the date of the most recent update to this document: http://www.bop.gov/resources/health_care_mngmt.jsp Federal Bureau of Prisons Anticoagulation Protocol Clinical Guidance March 2018 WHAT’S NEW IN THIS DOCUMENT? The following changes have been made to the BOP Anticoagulation Protocol since it was last issued in April 2013: • A new table has been added to Section 4, Heparin Products. See Table 2. Dosing of LMWHs for Treatment and Prevention. • In Section 5, Warfarin, the discussion has been expanded to include lifestyle factors and health conditions affecting warfarin therapy. See Interactions with Food, Drugs, Lifestyle, and Health Conditions. • A new Section 6 on Novel Oral Anticoagulants (NOACs) has been added. • Information on Treatment of Deep Venous Thrombosis (DVT) and Pulmonary Embolism (PE) has been updated in Section 7. • The Inmate Fact Sheet on Warfarin is now available in Spanish. See Appendix 9B. • The CHA2DS2-VASc score has replaced the CHADS2 score for predicting thromboembolic stroke risk in non-valvular atrial fibrillation. See Appendix 10, Table B. i Federal Bureau of Prisons Anticoagulation Protocol Clinical Guidance March 2018 TABLE OF CONTENTS 1.
    [Show full text]
  • Ventricular Assist Devices As Destination Therapy: INSIDE FALL 2013 Why and When to Make This Decision
    ADVANCES IN ADULT AND PEDIATRIC CARDIOLOGY, INTERVENTIONAL CARDIOLOGY, AND CARDIOVASCULAR SURGERY Affiliated with Columbia University College of Physicians and Surgeons and Weill Cornell Medical College Ventricular Assist Devices as Destination Therapy: INSIDE FALL 2013 Why and When to Make This Decision End-stage heart disease affects some six million Americans a year and is the principal diagnosis 1 VADs: The Early Years of patients discharged from hospitals. Despite many advances in medical therapies, it is estimated that over one million patients will progress to significant heart failure with high mortality rates. In recent years, left ventricular assist devices (LVADs) have transitioned in their role as a bridge- 2 The Right Time to VAD to-transplant to a destination therapy for patients with advanced heart failure. While these devices are highly effective in prolonging survival in patients refractory to medical management, Exciting Progress, they are not without their challenges. This article addresses some important questions about the Continuing Challenges: decision-making process for recommending an LVAD as a permanent therapy and the associated 4 Weighing Risk Versus risks and benefits to patients. Benefit ccording to Yoshifumi Naka, MD, APhD, Director of the Mechanical The Next Generation Circulatory Support Program and 5 Cardiac Transplantation Program at NewYork-Presbyterian, the Mechanical Circulatory Support Program at NewYork-Presbyterian/Columbia was initiated in 1990 to provide a bridge-to- transplantation to support patients until suitable donor hearts became available. In the two decades since, cardiologists and cardiothoracic surgeons at NewYork- Presbyterian/Columbia and NewYork- Presbyterian/Weill Cornell have reached In the most recent edition across their subspecialties, pooling their expertise to find a viable therapy for of America’s Best Hospitals end-stage heart failure when medical published by therapies have nothing left to offer and U.S.News & World Report, transplant is not an option.
    [Show full text]
  • Left Ventricular Assist Device As Destination Therapy
    The VAD Journal: The journal of mechanical assisted circulation and heart failure Review Left Ventricular Assist Device as Destination Therapy Maya Guglin 1 * and Leslie W. Miller 1 Gill Heart Institute, University of Kentucky, Lexington, KY 1 ORCID: 0000-0001-5746-3135 * Corresponding author: [email protected] Abstract Mechanical circulatory support is the most rapidly evolving strategy in heart failure management. The growing number of patients who need better results than medical therapy can offer, the limited pool of donors for cardiac transplantation, and several technological breakthroughs have all made the option of implanting a left ventricular assist device (LVAD) as destination therapy Citation: Guglin, M., et al. (2014). Left Ventricular Assist Device as more important. Destination Therapy. The VAD Journal, 1. doi: In this review, we outline the indications and decision making process of http://dx.doi.org/10.13023/VAD.2 014.02 considering a patient for a destination therapy LVAD, as well as outcomes, complications, and issues related to management of patients on currently Editor-in-Chief: Maya Guglin, University of Kentucky approved devices. The future direction of the field will be determined by progress in technology and by further improvement in size, durability, pump dynamics, and Received: Dec. 30, 2014 most importantly, by solving the problem of supplying energy to the pump without Published: Dec. 30, 2014 a percutaneous driveline. © 2015 The Author(s). This is an open access article published under the terms of the Creative Keywords Commons Attribution- NonCommercial 4.0 International Heart failure; Ventricular assist device; Mechanical circulatory support License (https://creativecommons.org/lice nses/by-nc/4.0/), which permits unrestricted non-commercial use, End Destination of Heart Failure Is LVAD distribution, and reproduction in any medium, provided that the The population of patients with heart failure (HF) is growing at a rate approaching original author(s) and the that of an epidemic.
    [Show full text]
  • VHA Directive 1102.08, Heart Failure Treatment Utilizing a Ventricular
    Department of Veterans Affairs VHA DIRECTIVE 1102.08 Veterans Health Administration Transmittal Sheet Washington, DC 20420 April 19, 2019 HEART FAILURE TREATMENT UTILIZING A VENTRICULAR ASSIST DEVICE OR TOTAL ARTIFICIAL HEART: PATIENT SELECTION AND FUNDING 1. REASON FOR ISSUE: This Veterans Health Administration (VHA) directive provides the policy for the use and funding of Ventricular Assist Device (VAD) therapy for destination and bridge to transplantation and Total Artificial Heart (TAH) therapy for bridge to transplantation, including guidelines for patient selection. 2. SUMMARY OF MAJOR CHANGES: Changes to this directive include the following: a. Added oversight responsibilities for the Under Secretary for Health and The Deputy Under Secretary for Operations and Management (see paragraph 5, Responsibilities). b. Added responsibilities for the Health Care team who performs pre-procedural evaluation, the implantation of the VAD or TAH device, and subsequent follow-up care and treatment for the Veteran (see paragraph 5, Responsibilities). c. Added Training paragraph, specifying that there is no mandatory training requirement (see paragraph 8). d. Added Records Management paragraph (see paragraph 9). 3. RELATED ISSUES: None. 4. RESPONSIBLE OFFICE: The VHA National Surgery Office (NSO) (10NC2) is responsible for the contents of this directive. Questions may be referred to the National Director of Surgery at 202-461-7130. 5. RESCISSIONS: VHA Directive 2012-033, Heart Failure Treatment Utilizing a Ventricular Assist Device or Total Artificial Heart: Patient Selection and Funding, dated November 9, 2012, is rescinded. 6. RECERTIFICATION: This VHA directive is scheduled for recertification on or before the last working day of April 2024. This directive will continue to serve as national VHA policy until it is recertified or rescinded.
    [Show full text]
  • Management of Anticoagulation in the Hospitalized Patient
    10/26/2015 MANAGEMENT OF ANTICOAGULATION IN THE HOSPITALIZED PATIENT Tracy Minichiello, MD Professor of Medicine University of California,, San Francisco Chief, Anticoagulation & Thrombosis Service San Francisco VA Medical Center Disclosures • none 1 10/26/2015 Cases • Should this patient be bridged perioperatively? • How do I manage this new oral anticoagulant perioperatively? • Should this patient on warfarin with GI bleed restart anticoagulation and if so when? • How do I manage this patient who is bleeding on anticoagulation? • Which anticoagulant can I use if my patient is morbidly obese? Case #1 Which of these patients should receive bridge therapy postoperatively 1. 75 yo man AFIB CHADS2=4 (HTN, CHF, DM) on warfarin s/p L hip fx repair. 2. 50 year old man on warfarin for recurrent VTE, last event June 2012 s/p bowel resection 3. 65 year old man on warfarin with mechanical mitral valve s/p bowel resection 4. All of the above 2 10/26/2015 Perioperative Anticoagulation • Does anticoagulation need to be stopped? • How many days prior does anticoagulation need to be stopped? Which agent What is renal function • Should this patient be bridged? ACCP Guidelines • In patients with a mechanical heart valve, atrial fibrillation, or VTE at high risk for thromboembolism, we suggest Bridging anticoagulation instead of no bridging during interruption of VKA therapy (Grade 2C) • In patients with a mechanical heart valve, atrial fibrillation, or VTE at low risk for thromboembolism, we suggest No bridging instead of bridging anticoagulation during interruption of VKA therapy (Grade 2C) • In patients with a mechanical heart valve, atrial fibrillation, or VTE at moderate risk for thromboembolism, The bridging or no-bridging approach chosen is based on an assessment of individual patient- and surgery-related factors Douketis JD.
    [Show full text]